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Nestled between China and India, Nepal is a mountainous and mostly rural country that has experienced years of political instability, making transport and communications especially difficult. The rugged terrain often prevents people from accessing health care, and many women give birth at home without the presence of a skilled health worker. In addition, it is common for girls to marry in their teens, which is particularly problematic as young women have an increased risk of pregnancy and childbirth complications.

Yet despite the topographic, financial and cultural barriers to availability and access of care the country faces, progress is being made. Last month, Nepal received a country MDG Award for outstanding national leadership, commitment and progress toward achievement of Millennium Development Goal 5, reducing maternal mortality. The maternal mortality ratio (MMR) has decreased from 830 deaths per 100,000 live births in 1990 to 229 in 2008. How has Nepal managed to do this? Through government leadership and support of partnerships, initiatives and programs that range from training and providing incentives to changes in policy, including the legalization of abortion.

Nepal has achieved reductions in maternal and child mortality in large part as a result of training 50,000 female community health volunteers (FCHV) to serve rural areas. The FCHV Programme was started in 1988 by the Ministry of Health and Population to provide a variety of public health needs including family planning, maternal care, child health, vitamin A supplementation/ de-worming and immunization coverage. The domino effect of the programme’s impact promotes maximum benefits to the community: Once FHVCs receive education and leadership training, they then go on to educate and inform other women about healthy pregnancy and childbirth.

Because so many births still take place outside of the hospital, some efforts focus on reaching out to rural women. For example, the community-based postpartum hemorrhage prevention initiative launched as part of the Nepal Family Health Program II, provides counseling and distribution of misoprostol by FCHVs for prevention of postpartum hemorrhage in deliveries not attended by a skilled provider. Others are trying to change the trend of home births. The Safe Motherhood Program financially reimburses expectant mothers for attending antenatal care (ANC) visits, delivering in the hospital, and receiving post-natal health services.

Nepal legalized abortion in 2002, and more recently has supported the training of health workers to counsel women and provide medical abortion. They were the first country to introduce Medabon®, a combination of mifepristone and misoprostol specifically packaged for use in abortion care, the first medical abortion product to do so and to be licensed as a combination product. This has expanded rural women’s access to safe services.